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EV <br />Backwater Prevention Device <br />Property Own� r Rebate Form <br />Backwater Prevention Device Rebate Form <br />P�int and return this form :vith your rebate packac�e <br />Property Owner Name: <br />Property address: 'Z� D �� I R.0 I}.I I� hY� �= ^_. <br />City: _ CUC� �=�— — State: �`'I,J �S'" Zip:����%' ^�� �� <br />Mailing address (i( ddferenl): <br />City: - -- -- Stztc: .--_� Zip: _ <br />�z,�n�a 1 c. <<-O'�'11 <br />Email address: ����i Q� � � - -- Phone: ( �ZS! ) Z>Z '� S ��� <br />Cost lo install Backwater Prevention Device: S__ __ <br />Rebate Package Cl�ecklist <br />I'lease chcck tha� y�u h�t�e r.ornpl �ted anci inr.luded �he lollm.ving iterns in your <br />:;ubmission Iterns rndic:ited as (CUNTRACTOR] i;d1l b�� providrd ;o you 6y }�our <br />r:nnlractof. <br />_�te r.on�pleted Rack�:�ater Pi�i-enl:���� n�i�ia: Reb„tc Form (lhis lorni) <br />� i� �4�p o( ihe property e�ith <br />[CONTRACTORj <br />lor.ation of inslalled E3ackwater Preventio�i Device <br />_� cupy of the compicted B��claa�ater Prevention Dewce Final Inslallation Checl<list <br />[CONTRACTORj <br />�_�; The itemized invoice show�ing business name, address, license number and detailed <br />r.��sts uf inslallation and mateiials. [CONTRACTOR]. Note: No rebate w�i�l excecd thc <br />r�>tal c st o( Ihe instnll��fion of the bar.lavatarprevention device worlc. <br />� i A Vendor Payment Option Form sic�ned by hoth the property owner and contractor IF <br />you wnuld like the City of Fverett to pay the ConUactor direr.tly. Ulherwise, lhe rebate <br />�:her.k will 6e rnade oul and delivered to you. <br />;—�cornpleted and signed Forrn W-9 (Request for �Taxpayer ldontiflcation Number and <br />Certification) <br />i't���c 1 or 2 <br />flevi5ed'J!�:0['�': D'�.�i <br />